Kenyan Health Care Suffers From Underfunding and Corruption

Following recent remarks by Kenya's Health Services Minister, Professor Anyang' Nyong'o, to the effect that there major problems with health care provision in the country, there have been a couple of other articles on the same subject.

One of them calls for greater investment in the health sector and suggests that problems in the sector are common knowledge. The article is not very specific and doesn't cite the study it purports to be referring to but it mentions inadequate staffing, drug shortages, lack of equipment and paucity of facilities.

The article claims that conditions are worse in rural than in urban areas, which is debatable, but it says that the rural, slumdwelling poor "simply lack access to quality health services". Indeed, I'd say that in some places people lack access to any health services, quality or otherwise. Staff shortages, the article goes on, leads to the use of shortcuts, longer procedures are avoided and quick fixes are widely used.

Apparently corruption is also a problem in the health sector and "Provisions to public health facilities end up in the hands of crooks, who sell them to private hospitals." The article concludes by calling for more investment, but perhaps any finance or resources involved need to be more carefully monitored as well.

Another article deals specifically with corruption and mismanagement in the sector. Both the Medical Services and the Public Health ministrys are mentioned (there are two on account of the power sharing agreement made following the post-election disputes in 2008). This article also mentions shortages of drugs and poor supervision.

According to the article, the report by the Kenya Anti-Corruption Commission "found absenteeism by medical staff, flawed procurement processes, theft of drugs and other medical supplies, and unnecessary referral of patients to private clinics as major forms of corruption." There is also, apparently, a lack of clarity about fees that patients are charged.

Minister Nyong'o specifically draws attention to the possible contribution that unsafe health services could make to the HIV epidemic and various other blood borne viruses. But the health problems that Kenyans face are numerous. In addition to greater awareness about these there should also be far more spending on safe health care that is accessible to everyone.

Who Will Educate the Educators?

After leaving Maker Faire Africa on Friday, inspired by much of what I saw there, I returned to Nakuru, where many of the town's residents stand or sit in the same places every day, staring at passers by, shouting the odd bit of abuse and joining in any commotion that happens to relieve the monotony.

I admit, I was a bit annoyed when I compared how some people do amazing things with their time and others do not. I always have to go through the same thought process; first I get exasperated and then I remember that there can be reasons why some people energetically pursue things that benefit them and others while some people seem condemned to get up every day and stare into the middle distance until it gets dark.

The vast majority of exhibitors that I talked to at Maker Faire were well educated and some were clearly from well off backgrounds. This means nothing on its own. Those with lots of education from well off backgrounds can also end up doing little with their lives. And some from poor families with only a basic education achieve great things.

But some of the exhibitors were also wondering why some of their fellow Africans didn't do what they were doing. And one reason I would suggest is lack of basic education and training in skills that allow people to prosper, or at least to get by better than they do now. When I attempted to demonstrate to people around Nakuru how they could make and use simple technologies, they went through a few phases: they were curious, even surprised; they raised objections; they became silent and sat on their hands.

I admit, they may not have had the best teacher. But I think there is something about education beyond what is imparted by a teacher and embraced by a learner. People didn't sit on their hands because they were unable to cut out shapes using patterns and stick things together with glue. They are well able to do such things and many others. I would guess that most of them could have done much of what the exhibitors at Maker Faire did.

What people gain from education, I hope, is the ability to make what they learn part of their day to day lives, whether this involves various bodies of knowledge or sets of skills. What people with a poor education receive is lists of things to learn off so that they can get the requisite number of ticks in order to graduate to the next class. These ticks are rarely, if ever, of any use to people thereafter. But once people have mastered the pretence of being educated, they have no way of taking their education further.

I'll say it again, people with education and training may not necessarily do much with it. And those with little education and training may spend their lives enhancing what they have got and benefiting themselves and those associated with them. But that seems like leaving things to chance for the majority, while allowing a minority quite an advantage, whether they use it well or not.

Development projects can be very narrowly focused. For example, many education projects focus on a few indicators, often the ones that show the project in a favorable light but give little benefit to the recipients. They might concentrate on enrolment but not attendance, exam results without any evidence of learning or the ability to continue learning after school has finished, gender parity without any change in genuine inequalities, etc. 'Success' in development projects can resemble the 'success' of students who have received a poor education.

HIV projects can involve huge amounts of money and produce amazing statistics about the number of HIV transmissions prevented, the number of deaths averted and the number of condoms distributed. Yet people are suffering from and dying from very ordinary diseases that are easy to prevent and cure. Health is not just a matter of disease or being free of disease and it's even less a matter of one virus (which is still endemic in many countries in the world, despite hundreds of millions having been spent on 'prevention' programs).

There seems to be an emphasis on size and magnitude and the measurement of these development projects, as if there is some great prize to be won on the basis of a few hackneyed quantities. Is the aim of development not to ensure that there are fewer millions of people receiving little or no education, suffering from and dying from preventable and treatable illnesses, unable to afford basic nutrition or water and sanitation? Of course you have to count people, but people are not indicators, nor are health or education.

Many of the projects at Maker Faire were about things that matter to people in their day to day lives, food, water and sanitation, agriculture, communication, income, energy, lighting, raw materials and the like. There was less emphasis on education that I would have expected, unless you count some electronic device that 'helps children learn to read'. But these are all concerns that are raised when you go to villages, slums and isolated areas.

Levels of education, especially among girls and women, can be shockingly bad. Many primary school teachers are said to have a low understanding of the subjects they teach and even those who know more don't manage to impart much. But education is not just a process of 'attaining' a set of facts or skills. It is the preparation that everyone needs in order to ensure the education and health of themselves and their families and to ensure that they grow up to be able to provide for themselves and their families, in turn.

A lot of development is dominated by quantities and measurement, a set of boxes to be ticked, regardless of the irrelevance of such processes to people's lives and livelihoods. The Millennium Development Goals, mentioned several times at Maker Faire, are the epitome of such a lifeless and administrative view of development. People need basic things, education, health, nutrition, income, water and sanitation and infrastructure, but they also need to be able to provide themselves with these and other rights. These are not things you can pack in sacks and send them off in an aid convoy.

Significant feats will not be achieved by hordes of administrators with clipboards (or technological variants of clipboards) recording a handful of indicators as people die prematurely and needlessly, though this is a great way of spending billions of dollars. I suppose development will only achieve anything when it has put people in developing countries in the position where they can do the development. So far, we have not been very good at this (and I include myself, of course).

That development needs to be sustainable, that it needs to give rise to further development, seems clear. But it also seems to matter a great deal who is doing the development, who is able to do it, whether it is outsiders from developed countries or insiders from developing countries. Which is very similar to the conclusion I came up with yesterday! I could go on, but tomorrow is another day.

Technology is the Preserve of the Rich

Every time I see an article talking up technology in Kenya and in Africa in general, I wonder which aspect of people's lives will be transformed. Over the last few weeks myself and my colleagues from Ribbon of Hope Self Help Group have been visiting families who never complain about having little access to technology. They have very little money and little access to loans. They are often surrounded by mud roads, living a long way from the sealed roads, which are often in bad repair. There is little or no affordable public transport.

Their children sometimes have very little food, no access to clean water or improved sanitation, decent clothing, books and other basic things that they need just to be able to attend school. If children become sick, their parents have to decide between taking them out of school and treating them or leaving them in school and hoping for the best. Hospitals are a long way off, they are expensive and they are poorly equipped and staffed.

Distance education would be great for children who had basic education. But only about three quarters of children even enroll for primary school, let alone finish. And just over 40% enroll for secondary school. Even at university or tertiary level, something few ever reach (despite some great official figures), elearning cannot replace teachers, books and indeed, access. Those who have got to university are already a small percentage of Kenyans who have not been denied any of the many things that poorer children will always be denied.

One of these idiotic sites that produces lots of puff about technology says "Kenyan Universities are increasingly turning to e-learning as tool to facilitate improved education". Will this improve education? It may be a new medium for some educational content but I'd like to see research that shows that education is in any way better for being delivered by electronic means. Computers are also in short supply and skills can be non-existent, especially among those who rarely have access to a computer.

Young children, especially in rural areas, where about 80% of Kenyans live, often don't have electricity or a private place to study, or even their own personal copy of the necessary text books. Some, especially girls, have to do chores around the house and farm when they should be studying. And many have to do work in the fields and in other jobs when the need arises. These are not technology related problems.

Technologies, I suspect, work when other infrastructures are in place. A farmer can, as these fatuous articles often claim, find out the market price of a commodity by mobile phone. But if there is no road, or if the road is impassible, or transport unaffordable, what's the point? Another claim is that medical stocks and medicines can be monitored electronically. The biggest problem in a lot of hospitals is the shortage or staff and medicines. Who is going to do the stocktaking and what stock are they going to monitor if there is not an adequate supply of drugs?

If the problems that most people experience can be relieved by various technologies, great. If everyone has access to these technologies and things in Kenya can change radically, wonderful. But if all these articles want to show is that some people use and like and even profit from technology, they are pointless articles, only useful to people who are already convinced that technology will pull everyone out of every problem them currently face. Technology will not solve problems of inequalities between rich and poor, between males and females, between rural and urban dwellers. Technology seems, at present, to be the preserve of the rich. And if their past behaviour is anything to go by, it will stay that way.

Good News for UNAIDS: We Know How to Turn Off the Tap

An article in the New York Times suggests that the "war on global Aids" is falling apart. Although drug prices have fallen dramatically and the number of people on antiretroviral drugs has risen, this effort to give HIV drugs to everyone that needs them has proved to be unsustainable. In countries like Kenya and Uganda, most of the funding was provided by donors who are now reducing funding, partly, they say, because of the global financial crisis.

But the article suggests that the financial crisis is not the only reason. Big donors are disillusioned at their lack of success, despite spending huge amounts of money on the problem. "For every 100 people put on treatment, 250 are newly infected"; prevention programmes have either been too expensive or almost completely ineffective or both. Donors are now going to turn their attention to cheaper diseases.

Using an often used metaphor, Dr David Kihumuro Apuuli, DG of the Uganda Aids Commission says that "You cannot mop the floor when the tap is still running on it". The executive director of the Global Fund to Fight Aids, TB and Malaria is "frustrated", a researcher from the National Institute of Health is "pessimistic", Obama's Aids Ambassador is "worried", the executive director of UNAIDS is "scared" and the former executive director "has seen optimism soar and then fade".

Well, David, Michel K, Anthony, Eric, Michel S, and Peter, there is a way to reduce the flow from the tap, even if we don't know how to turn it off completely. This may eventually reduce the flow to a trickle and the number of new HIV cases every year could become so small that there is no longer an epidemic. Yes, a new direction is required, but this new direction has already been researched carefully and described by a number of experienced researchers.

Here's what we need to do: we need to re-evaluate the considerable evidence that unsafe medical practices are contributing a lot more to HIV transmission than is currently estimated by UNAIDS. We also need to include in this re-evaluation unsafe cosmetic practices, especially those that, either accidentally or on purpose, draw blood and thereby contaminate instruments.

Aids spending has concentrated overwhelmingly on treatment for much of the last three decades. And much of the money spent on preventing new infections went on mother to child transmission and some rather hopeless exhortations to abstain from sex, reduce numbers of partners and use condoms. Safe sex and increasing condom use are very important for reducing sexually transmitted HIV but they are completely useless when it comes to non-sexually transmitted HIV.

To continue the rather tired metaphor, UNAIDS and many other concerned parties have been turning the tap the wrong way, because anyone infected non-sexually can go on to infect others through sexual contact. Those who are now disillusioned because the number of people becoming newly infected every year still exceeds the number receiving treatment may be inspired when they see this trend slowing down. They may be persuaded to continue paying for more treatment if they think that the numbers of new infections will go down every year from now on.

It has been obvious for a long time that the small number of countries in the world where the vast majority of HIV positive people live are not inhabited by people who have unbelievable numbers of sexual experiences with incalculable numbers of sexual partners. Indeed, only a very dedicated adherent to some long discredited and rather racist views of African people could even countenance such an explanation.

So, HIV prevention is not so intractable as some would have us believe. Yes, it's hard to influence sexual behaviour to any great extent. But if less HIV transmission can be put down to sexual transmission then a lot of money currently being spent on the programmes that are not working can be saved for something worthwhile. And money spent on health services now will result in immediate savings. Ensuring safer medical and cosmetic practices will prevent both direct infections and the indirect infections caused by those infected directly, either sexually or non-sexually.

I call on UNAIDS and all those working in the field to take the official advice, to 'Know your epidemic (or pandemic), know your response'. To understand why HIV has been spreading the way it has in high prevalence countries, we need to look at the most efficient ways of spreading the disease: blood contact. A combination of unsafe medical practices and unsafe cosmetic practices is continuing to spread HIV simply because the official view is that HIV is predominantly spread by unsafe heterosexual sex in high prevalence countries and that blood exposures are so rare as to be insignificant. You know your response has failed, therefore, how well do you know your epidemic?

Medical Transmission of HIV May Be Widespread in African Countries

A couple of weeks ago I was taken to see a woman in a rural area who was very sick. She was terribly emaciated and the place she lived in had clearly not been looked after for a long time. The woman insisted that she did not have HIV, although she also claimed not to have been tested. After a few days, she was taken to the local health centre. There, it turned out that she had already been tested for HIV, was found to be HIV positive and was put on antiretroviral drugs (ARV). But she refused to take the drugs and agreed to be sent home, as the health centre was unable to do anything for her. She died about one week later.

All we could do was insist that she went to the health centre to be tested and take her drugs. She reluctantly went to the health centre but refused to take her drugs. It was as if that was all that was left to her to preserve her dignity. For some time, she had refused the advice of neighbours and health volunteers. And they were growing less willing to visit her, because they knew that she was going to die. On the day she went to the health centre, she looked humiliated and perhaps even angry.

The stigma that still attaches to HIV/Aids, and even TB because of its association with HIV, may seem like a sticking point that results in people wishing to deny that they have been infected, even when the cause of their illness is undeniable. But the stigma is real. People are ostracized and treated differently because they have a disease that is associated with illicit sexual activity, either on the part of the sick person or on the part of someone with whom they are intimately connected.

The 'behavioural paradigm' for explaining HIV transmission is widely adhered to and informs most HIV prevention programmes. From the extremely naive ABC (Abstinence, Be faithful, use a Condom) to the downright foolish mass male circumcision (MMC) campaigns, the assumption is that because HIV is mostly transmitted by sexual intercourse, all we need to do is get people to change their sexual behaviour.

So far, I have accepted the often published claim that most HIV is sexually transmitted. But I have argued that the circumstances in which people live and work, for example, may determine who they have sex with, when and under what conditions. Trying to influence their sexual behaviour without examining these circumstances too, will result in a lot of failed prevention programmes. Most prevention programmes to date have, indeed, failed.

But perhaps, while rejecting the behavioural paradigm, I have fallen into the trap of accepting something like a sexual paradigm, that most HIV transmission is sexual transmission. Perhaps this is not even true. I was aware that there were people arguing that non-sexual, particularly medical transmission, could be far higher than accepted by many theorists. But I had to exclude certain lines of enquiry in order to limit my dissertation to a manageable field. Now that I am no longer so constrained, I have time to revise this limitation.

If medical transmission of HIV is significantly more common than supposed by most HIV analyses, a lot of questions could be answered. For example, perhaps more women than men, especially women of childbearing age, are infected because they receive more medical treatment. Perhaps many children who have been infected, especially those whose mother is not infected, have been infected by medical treatment. Perhaps the reason those in Northern Kenya, who have least access to modern medicine, also have very low levels of HIV because they are not being infected by medical procedures.

I have been reading a book by Daivd Gisselquist called Points to Consider: Response to HIV/AIDS in Africa, Asia and the Caribbean, conveniently published on the internet. Some of the things revealed in this book are truly shocking. When I have finished, I have to go through everything I have written about HIV and reconsider my whole view of it. My view of development will probably remain the same, but the way I reached some of my conclusions will have to be revised, considerably.

If Gisselquist and others are right, and I have no reason to believe they are are wrong, the woman who refused to take her medication could have been a victim of stigma, not primarily emanating from her own neighbours, but from some of the most eminent health professionals in the world. That HIV is primarily sexually transmitted in African countries is a long held, received view. Because of this received view, people who say they have not had sex in the period in which they became infected have not been believed. Women who are infected when their husbands are not are assumed to have had extramarital sex. Where couples are infected with different strains of HIV, they are both assumed to have been promiscuous, rather than just one of them.

This received view is in need of thorough testing and it is incredible that it has been used to face down challenges for so long. The view has shaped most of the (highly unsuccessful) prevention campaigns, but also people's reaction to their being infected with HIV or the reaction of others when faced with someone who has been infected. How many innocent people may have died in shame, misery and isolation because the health profession has refused, for whatever reason, to investigate its poorly supported assumptions about frequency of transmission of HIV in medical contexts?

Punishing Victims; Protecting Perpetrators

Several Christian organisations and churches in Kenya are claiming 'victory' because the draft constitution has been rewritten to specify that life begins at conception. They threatened to sabotage the whole constitution if this was not done. As a result of their threats, other clauses have also been removed. Kenyans will not now have a right to health care, in particular, reproductive health care. Also, the clause stating that no one may be refused emergency medical treatment has been removed. And there is a phrase that specifically rules out abortion unless the life of the mother is in danger.

Abortion is already illegal in Kenya, but this has not prevented several hundred thousand woman and girls seeking abortion every year. The majority of these abortions, an estimated 800 per day, are unsafe, being carried out in insanitary conditions by untrained personnel. Those who go through these unsafe abortions are less likely to seek professional medical attention and less likely to receive it. As a result, over 2000 die every year, adding considerably to the thousands of maternal deaths that occur.

In what sense have these Christian groups achieved a victory? They don't appear to be opposed to the fact that rape and forced sex often goes unpunished because it is carried out by the more powerful against the powerless. It is carried out by adults against young people, even children. Those who should protect the victims, church leaders, political leaders, teachers, police and others, are often the perpetrators.

If, as Christians are so fond of claiming, life is sacrosanct, why are the lives of certain people so unimportant? Why are human lives so unimportant as to be denied the right to health and the right to make their own reproductive decisions? Women should be able to choose when to have children, under what conditions and with whom. Where these rights have been denied, why should they be made to pay for someone else's crime?

Nothing that these Christians have done will reduce the incidence of unsafe abortions, of seriously compromised reproductive health for women, of women suffering and dying unnecessarily. Nothing that these Christians have done will reduce the incidence of rape and forced sex. Victims of crime should be entitled to protection, not punishment. Perpetrators of crime deserve punishment, especially when those perpetrators are in a position that gives them a level of power that they subsequently abuse.

One priest has said 'we should not victimise the innocent unborn children' but what about the woman or girl who has already been victimised and is now to be punished, perhaps for the rest of her life? Kenya is in dire need of good leadership and the interference of interested parties, whether they be political, religious, commercial or whatever else, is frustrating this need. The country also needs good health care and equal rights for all people, regardless of gender, sexual orientation, tribe, wealth and anything else. But some of the Christian churches clearly have other ideas.